https://doi.org/10.1590/0004-282X20170148 ARTICLE Good sensory recovery of the hand in brachial plexus surgery using the intercostobrachial nerve as the donor Boa recuperação da sensibilidade da mão usando o nervo intercostobraquial como doador em cirurgia do plexo braquial Luciano Foroni1, Mário Gilberto Siqueira1, Roberto Sérgio Martins1, Carlos Otto Heise2,3, Hugo Sterman Neto4, Adriana Yoriko Imamura5 ABSTRACT Objective: Restoration of the sensitivity to sensory stimuli in complete brachial plexus injury is very important. The objective of our study was to evaluate sensory recovery in brachial plexus surgery using the intercostobrachial nerve (ICBN) as the donor. Methods: Eleven patients underwent sensory reconstruction using the ICBN as a donor to the lateral cord contribution to the median nerve, with a mean follow-up period of 41 months. A protocol evaluation was performed. Results: Four patients perceived the 1-green filament. The 2-blue, 3-purple and 4-red filaments were perceptible in one, two and three patients, respectively. According to Highet’s scale, sensation recovered to S3 in two patients, to S2+ in two patients, to S2 in six patients, and S0 in one patient. Conclusion: The procedure using the ICBN as a sensory donor restores good intensity of sensation and shows good results in location of perception in patients with complete brachial plexus avulsion. Keywords: brachial plexus; intercostal nerves; median nerve; nerve transfer; sensation; perception. RESUMO Objetivo: A restauração da sensibilidade em pacientes com lesão completa do plexo braquial é muito importante. O objetivo desse estudo foi avaliar a recuperação sensitiva em cirurgia do plexo braquial utilizando o nervo intercostobraquial (NICB) como doador. Métodos: Onze pacientes foram submetidos a reconstrução sensitiva usando o NICB como doador para a contribuição lateral do nervo mediano, com tempo de acompanhamento pós-operatório médio de 41 meses. Um protocolo de avaliação foi realizado. Resultados: Quatro pacientes perceberam o filamento 1-verde. Os filamentos 2-azul, 3-roxo e 4-vermelho foram percebidos por um, dois e três pacientes, respectivamente. Um paciente não apresentou recuperação sensitiva. Dois pacientes obtiveram recuperação S3, dois S2+, seis S2 e um S0, pela escala de Highet. Conclusão: O procedimento usando o NICB como doador promove boa intensidade de recuperação sensitiva e bons resultados são obtidos quanto ao local de percepção em pacientes com avulsão completa do plexo braquial. Palavras-chave: plexo braquial; nervos intercostais; nervo mediano; transferência de nervo; sensação; percepção. The treatment of complete brachial plexus avulsion In a previous study, our group demonstrated the anatomi- remains a challenge for nerve surgeons1,2. The recovery of cal feasibility of using the intercostobrachial nerve (ICBN) motor function continues to be the priority in brachial as a donor of sensory fibers to the lateral cord contribution to plexus reconstruction, but restoration of the sensitiv- the median nerve (LCMN)3. The purpose of this study was to ity to sensory stimuli in the hand of patients who have report the detailed clinical results of sensory recovery in the regained movement and function in their arms should hand, using this technique in patients with complete brachial also be a priority. plexus injury. 1Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Divisão de Neurocirurgia Funcional, Grupo de Cirurgia de Nervos Periféricos. São Paulo SP, Brasil; 2Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Neurologia, São Paulo SP, Brasil; 3Instituto Fleury, Departamento de Neurofisiologia, São Paulo SP, Brasil; 4Universidade de São Paulo, Departamento de Neurologia, Divisão de Neurocirurgia, São Paulo SP, Brasil; 5Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Terapia de Mão, São Paulo SP, Brasil. Correspondence: Luciano Foroni; Rua Mateus Grou, 340 / apto. 22; 05415-040 São Paulo SP, Brasil; E-mail: [email protected] Conflict of interest: There is no conflict of interest to declare. Received 30 July 2017; Accepted 14 August 2017. 796 METHODS Sensory tests were performed with the patient’s eyes cov- ered. The sites of sensory testing were the first three fingers Patients and thenar eminence of the hand. All procedures performed in our study were in accordance with the ethical standards of the institutional and/or national Semmes-Weinstein monofilament test research committee and with the 1964 Helsinki declaration Pressure thresholds were evaluated using the and its later amendments or comparable ethical standards. Semmes-Weinstein monofilament test (Sorri-Bauru, Bauru, A prospective study was conducted from January 2010 to Brazil)4, with adequate technique. The filaments were differ- April 2013. Eighteen patients with complete brachial plexus entiated by colors as 1-green (0.05 g), 2-blue (0.2 g), 3-purple injuries underwent motor and, at the same time, sensory (2.0 g), 4-red (4.0 g), 5-orange (10.0 g) and 6-pink (300 g). The reconstruction. In all cases, the mechanism of injury was color black was used when no response was obtained. The high-energy trauma as the result of a motorcycle accident. lowest filament number detected reliably on two or more of Six patients were lost to follow-up and were not included in four trials was recorded. this analysis (patients 1, 4–7 and 15). Twelve patients with a sufficient follow-up period received a complete evaluation of sensory recovery of the hand by an experienced hand therapist and were included in this study. One of the patients was excluded later because he was surgi- cally treated with a DREZotomy (patient 8). The mean fol- ICBN low-up period was 41 months (range, 36–52 months). There were 10 male patients and one female patient. The mean age was 25 years old (range, 17–36 years old). The mean interval between injury and surgery for sensory reconstruction was LM 6.7 months (range, 2–11 months). Surgical technique Motor reconstructions were carried out on all patients and the sensory reconstruction was performed in the same surgery as follows: a longitudinal incision was made along the ante- rior axillary line starting in the posterior part of the lateral bor- ICBN: intercostobrachial nerve; L: lateral; M: medial. der of the pectoralis major muscle and prolonged downward Figure 1. Surgical photography of a lateral view of the thorax until the third intercostal space. Fat tissue in the axillar region showing the ICBN at its origin in the second intercostal space and crossing to the axilla. was dissected and carefully mobilized. The ICBN was identi- fied within this fat tissue emerging from the second intercos- tal space and dissected distally towards the lateral chest skin and axillar region. The ICBN was then transected distally and reflected towards the infraclavicular space to reach the LCMN M below the pectoralis major muscle. A deltopectoral incision ICBN was made, the cephalic vein was mobilized and the deltoid and the pectoralis major muscles were retracted apart. The pecto- ralis minor muscle was divided near its origin from the cora- LC coid process to expose the infraclavicular plexus beneath the fat pad. The LCMN was isolated and divided at its origin in the lateral cord, to be turned down towards the axilla. Depending on the length of the LCMN and of the ICBN, the coaptation LCMN was made in the infraclavicular region, in the axilla or below MCN the pectoralis major muscle. Two nylon 10-0 stitches and fibrin L glue were applied for coaptation (Figures 1 and 2). Evaluation of sensory recovery ICBN: intercostobrachial nerve; L: lateral; LC: lateral cord; LCMN: lateral cord contribution to the median nerve; M: medial; MCN: musculocutaneous nerve; A protocol evaluation was performed on 12 patients. ⋆ : point where the LCMN was sectioned from the LC to be turned inferiorly The sensitivity in the distribution of the median nerve in the for coaptation with the ICBN. Figure 2. After being sectioned distally and displaced in hand was evaluated when the advancement of the Tinel sign the subpectoral space, the ICBN reaches the LCMN in the reached the carpal region. deltopectoral groove. Foroni L et al. Sensory recovery in brachial plexus surgery 797 Location of perception of sensation RESULTS The location of perception of sensation in the median nerve territory of the hand was assessed using moving touch Ten patients perceived at least the 4-red filament at the terri- with the lowest monofilament detected. tory of the median nerve. The best result on Semmes-Weinstein monofilament testing was perception of the 1-green filament in Vibration perception four patients. The 2-blue filament was perceptible in one patient, Perception of vibration was assessed with a tuning fork the 3-purple in two patients and the 4-red in three patients. of 256-cycles/second stimuli touching directly on the sites of Six patients felt sensation only in the cutaneous distri- testing by the examiner. The results were recorded as being bution of the repaired nerve in the hand. One patient had perceptible or not perceptible and where the location of double sensation in the cutaneous distribution of both the perception was. median nerve in the hand and in the posteromedial aspect of the proximal arm that corresponded to the cutaneous dis- Temperature perception tribution of the ICBN. Three patients had referred sensitivity A steel bar warmed in 50°C hot water and an ice bar were only in the cutaneous distribution of the ICBN. used for these tests, and were recorded as warmth being per- Vibration with 256-cycles/second stimuli was perceived in seven patients. Ten patients had perception of both warmth ceptible or not, and as cold being perceptible or not, respec- and cold. None of the patients had two-point discrimination. tively. The steel bar and ice bar were touched directly on the One patient experienced no sensory recovery at all.